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Morning Report

Thursday, 23ndAugust 2018


Team On Duty
dr. Aswad Affandi ( Chief )
dr. M. Reza ( Jaga 1)
dr. Herdi Gunanta Syaiful ( Jaga 1)
dr. Sumrahadi Manurung ( Jaga 1)
dr. Indra Wijaya Putra ( Jaga 2)
dr. Muhammad Iqbal (Jaga 3)
dr. T. Fenny Novhera ( Jaga 4)
dr. Pria Desriady ( Jaga 5)
dr. Saddam Hussein Damanik ( Jaga 6)
RSUDZA dr. Indra Wisesa ( Jaga 7)
No. Distribution of surgery patient Room Total

1 Emergency Room Patient - 16 Patients


2 Hospitalize - 6 Patients
3 Out of Clinic - 10 Patients
4 Refuse Medical Advice - 0 Patients

• -
5 Passed Away -

6 Hospitalize Room Raudhah 1 18 /28 bed

Raudhah 2 24 /28 bed

Raudhah 3 20 /28 bed


Raudhah 4 20 /28 bed
Raudhah 5 16 / 28 bed
Raudhah 6 19 / 29bed
Raudhah 7 28 / 29 bed
ICU D 4 patients
ICU C 3 Patients
ICCU 1 Patient
PICU 2 Patients
NICU 5 Patients
ICU • Zakirah / 60 yo / Post BKA a.i PAD + CKD St.V on HD reguler / VIII
ADULT • M. Sufi / 60 yo / post op platting costae 4th – 8th + thoracotomy + chest tube hemithorax
dextra / II
• Muliadi / 17 yo / Post Craniectomy decompressieon due to ICH / POD I
• Mirnayanti / 22 yo / Post craniectomy due to EDH evacuation / POD I

ICU • Suryadi / 49 yo / Post craniectomy removal tumor due to ICH intra tumoral, POD XVI + Post
CARDIAC Vp.Shun a.i hidrochefalus, POD XI
• T. Firman Hidayat / 16 yo / VSD Closure / POD VII
• Salamun Bin Kaspen / 49 yo / Post craniectomy decompression with microsurgery due to
ICH evacuation ar. Frontal sin / POD 0

PICU • Azka Daffa / 7 mo / Post Drainage Abses a.i Abses Cerebri + Dyspneu ec. Dd.
Bronkopneumonia / POD 1
• Muhammad Sandriansyah / 11 yo / Penurunan kesadran e.c Edema Cerebri + close fracture
tibia fibula 1/3 tengah / AD II

NICU • M. Khalil / 23 do / Post Op VP Shunt due to Hydrocephalus non communican + Rupture


Meningoencephalocele / POD XIII
• By. Darmi / 6 do / Rupture Meningocelle + Hydrocephalus / AD XIII
• Miftahul Jannah / 5 do / Hidrocephalus / AD X
• By. Lisnawati / 5 do / Post colostomy due to malformation anorectal / POD V
• Muhammad Zhaky / 4 do / Hydrocephalus Non Communicant / AD1

3
Pasien Rawat Inap ( 6 Pasien )
No. Pasien Diagnosa Tindakan Keterangan
1 T. Noval, Lk, 14 thn, • CKS • Craniectomy evakuasi • HCU Surgical
1182493 • ICH ar Temporo Parietal ICH
Dex.
• EDH ar Temporal Dex.
• Fr. Depress ar Parietal
Dex.

2 M. Asyraf, Lk, 5 thn, • Open Fr. Tibia et Fibula • Debridement • Raudhah 2


1182495 Dex. 1/3 tengah grade 1 • ORIF
3 M. Syafawi, LK, 17 thn, • Fr. Maxilla Lefort 1 • ORIF Elektif • Raudhah 4
1182501 • Fr. Nasal • Elevasi Fr. Nasal
elektif
4 T. Abu Bakar, LK, 64 • Close Fr. Neck Femur • Arthroplasty elektif • Zamzam 4
thn, 1182510 Dex.
5 Muslim, Lk, 45 thn, • Total MBO ec HIL sin. • Laparotomy explorasi • ICU Dewasa
1182532 Inkarserata emergency
• Repair Defek Hernia
6 Fakri Husaini, Lk, 25 • Open Fr. Femur 1/3 • Debridement elektif • Raudhah 7
thn, 1182535 tengah • ORIF
• Post Debridement
Patient identity :

•Name : Muslim
•Age : 45 years old
•Sex : Male
•Address : Ds. Punie. Kab Aceh Besar
•MR : 1 16 25 32
•Admission Time : 02.15 WIB
Time Response

Date/hour Examination Laboratory Radiology Hour of Date/hour


patient hour Examination Examination Diagnostics patient out DPJP
came to ER from ER
Send Result Send Result
August 24th 02.20 02.20 04.00 - - 02.30 OR dr. M. Yusuf,
2018 Sp.B KBD
Wib Wib Wib Wib 08.30
02.15 Wib
Wib
Chief complaint:
• Abdominal distension

Presenting history:
• The patient referred from Harapan Bunda hospital to
dr. Zainoel Abidin hospital emergency room with chief
complaint Abdominal distension for 2 days
• The complain was accompanied by no defecation and
flatulence for 2 days
• The patient also complaint pain of the lump at the
left inguinal region
• Previously, the lump was intermittent for 2 years,
appeared when he was in activity and
disappeared when was lying down but in last 2
days the lump was settled.
• The pain was felt continuously.
• Patient was a driver.
• There were history of nausea and vomiting.
• There was history of persistent cough.
• There was no history of bowel habit change and
decreasing of body weight.
Physical examination:
• Level of consciousness : Apathies
• Blood Pressure : 70/50 mmHg
• Heart Rate : 112 beats/minute, pale and
cold extremity, CRT > 3’
• Respiratory Rate : 28 breaths/minute
• Temperature : 35,90C

L/S at the abdominal region


• I : Symmetrical, distention (+)
•A : Bowel sound (+) increased
•P : Pain (+), muscular rigidity (-)
•P : Tympani, liver dullness (+)
IAP : 17,5 mmHg
L/S at the left inguinal region :
• L : Lump (+), hyperemic (-), the margin of lump
was unclear
• F : Pain (+), the lump consistency was smooth,
fluctuative (-), warm (-)

Digital rectal examination:


• Sphincter ani : Tight
• Ampula rectal : Faeces (-), mass (-)
• Mucosa : Smooth, pain (-)
• At glove : Faeces (-), blood (-)
Assessment :
1. Total mechanical bowel obstruction due to
strangulated of the left lateral inguinal hernia
2. Septic shock
Management
• Stop oral intake
• Resuscitation IVFD RL 1500 cc + koloid 500 cc
• Maintenance IVFD RL 1800 cc / 24 hours
• NGT decompression  greenish
• Urinary Catheter  40 cc,yellowish
• Fosmicin inj 1 gr
• Metronidazole 500 mg
• Metamizole sodium 500 mg
• Ranitidine inj 50 mg
• Laboratory examination
• Radiology examination
Vital sign and urine

Time BP HR RR Temp Urine

03.00 90/70 112 26 37,0 50

05.00 100/70 112 26 36,9 40

06.00 105/80 110 24 37,2 50

07.00 105/80 106 24 37,4 50

08.00 105/90 108 24 37,1 60


Laboratory results:
• Hb : 17.1 gr/dL
• White blood count : 12.900/uL
• Platelet : 229.000/uL
• Ht : 45 %
• PT : 12.4 seconds
• APTT : 60.1 seconds
• Blood glucose ad random : 128 mg/dL
• Sodium : 139 mmol/L
• Potassium : 4.1 mmol/L
• Chloride : 103 mmol/L
• Ur/ cr : 129 / 2,94 mg/dL
AGDA
PH : 7, 230 mmHg
pCO2 : 52,10 mmHg
HCO3 : 22,0 mmol/L
p02 : 62 mmHg
Total CO2 : 23,6 mmol/L
BE : -5,4 mmol/L
Saturasi O2 : 86 %
Abdomen 2 position + Thorax erect

• Dilatation of bowel (+)


• Distal air did not reach pelvic cavity
Diagnosed:
1. Total mechanical bowel obstruction due to
strangulated of the left lateral inguinal hernia
2. Septic shock
3. IAH grade 2

Consult Digestive surgery division


• Laparotomy + Repair defect hernia
Operative Report
• Performed midline incision
• Peritoneum was opened  came out serous liquid
• Explored intestine  Colon was trapped in hernia
ring
• Colon was released  Found sigmoid colon was
hyperaemic viable
• Performed repair defect hernia with pull string
suture
• Bleeding control
• The wound was closed by primary suture
Post Operative Diagnosed:
Post laparotomy + repair defect hernia
1. Total mechanical bowel obstruction due
to incarserted of the left lateral inguinal
hernia (ICD 10 CM K59.69)
2. Septic shock (ICD 10 CM N.10)
3. IAH grade 2 (ICD 10 CM S.13)
Follow Up
Date S O A P
August On General condition: weak Post laparotomy + repair • IVFD NaCl 1500 cc/day
24 BP : 130/90 mmHg defect hernia • Inj. Meropenem 1g/8 hours
sedatio
2018 HR : 108 beats/min • Drip. Metronidazole 1500
n RR : SCMV mode 14
breaths/minute 1. Total mechanical mg/24 hours
Temp : 36.9º C bowel obstruction due • Inj. Omerpazole 40 mg/12
ICU D to incarserted of the hours
S/L ar Abdomen left lateral inguinal • Drip. Paracetamole 1 gr/8
POD 1 hernia (ICD 10 CM hours
- Inspection : Distention (+), K59.69) • Inj. Fentanyl 40mg/24 hour
darm contour (+) wound • Inj. Midazolam 3mg/24
operation closed by gauze 2. Septic shock (ICD 10 hour
Drain I : 100 cc /12 hours CM N.10) • Inj. Norephinephrine
(serous) 3. IAH grade 2 (ICD 10 0,45mg/24 hours
- Auscultation : Bowel sound (-) CM S.13) • Fasting
- Palpation : Muscular rigidity (-)
- Percussion : Liver dullness (+)
• Observation vital sign
Date S O A P
August On General condition: weak Post laparotomy + repair • IVFD NaCl 1500 cc/day
25 BP : 90/70 mmHg defect hernia • Inj. Meropenem 1g/8 hours
sedati
2018 HR : 110 beats/min • Drip. Metronidazole
on RR : SCMV mode 14
breaths/minute 1. Total mechanical 1500mg/24 hours
Temp : 36.9º C bowel obstruction due • Inj. Omerpazole 40 mg/12
ICU D to incarserted of the hours
S/L ar Abdomen left lateral inguinal • Drip. Paracetamol 1 gr/8
POD 2 hernia (ICD 10 CM hours
- Inspection : Distention (+), darm K59.69) • Inj. Fentanyl 40mg/24 hour
contour (+) wound operation • Inj. Midazolam 3mg/24
09.00 closed by gauze 2. Septic shock (ICD 10 hour
Drain I : 45 cc /12 hours (serous) CM N.10) • Inj. Norephinephrine
Wib - Auscultation: Bowel sound (-) 3. IAH grade 2 (ICD 10 0,45mg/24 hours
- Palpation: Muscular rigidity (-) CM S.13) • Fasting
- Percussion: Liver dullness (+)

• Observation vital sign


Date S O A P
August On General condition : Post laparotomy + repair defect hernia
25 sedatio Weak • Performed fluid resuscitation
2018 n BP : 90/70 mmHg 1. Total mechanical bowel obstruction
HR : 104 beats/minute due to incarserted of the left lateral
RR : 20 beats/minute inguinal hernia (ICD 10 CM K59.69)
ICU D
Urine : 15 cc/hr 2. Septic shock (ICD 10 CM N.10)
POD 2 3. IAH grade 2 (ICD 10 CM S.13)
S/L ar Abdomen
12.30 - Inspection : Distention (+), darm contour (+)
Wib wound operation closed by gauze
- Auscultation: Bowel sound (-)
- Palpation: Muscular rigidity (-)
- Percussion: Liver dullness (+)

August On General condition: Post laparotomy + repair defect hernia • Inj sulfas atropine 8 mg
25 sedatio Weak
2018 n BP : 70/60 mmHg 1. Total mechanical bowel obstruction  No Respone, EKG : Asistole
HR : 52 beats/minute due to incarserted of the left lateral
RR : 20 beats/minute inguinal hernia (ICD 10 CM K59.69)  Performed RJP 1 cycle
ICU D Urine : 5 cc/hr 2. Septic shock (ICD 10 CM N.10)
3. IAH grade 2 (ICD 10 CM S.13)
POD 2 S/L ar Abdomen

13.30 - Inspection : Distention (+), darm contour (+)


Wib wound operation closed by gauze
- Auscultation: Bowel sound (-)
- Palpation: Muscular rigidity (-)
- Percussion: Liver dullness (+)
Date S O A P
August On General condition: Post laparotomy + repair defect
25 sedation Weak hernia Inj sulfas atropine 4 mg
2018 BP: 40/20 mmHg Inj adrenaline 0,2 CC
HR: no beat 1. Total mechanical bowel
RR: 20 beats/minute obstruction due to incarserted Performed CPR  Family refused
ICU D of the left lateral inguinal
POD 2 medical advice & DNR
hernia (ICD 10 CM K59.69)
S/L ar Abdomen 2. Septic shock (ICD 10 CM N.10)
14.00 - Inspection : Distention (+), darm
FM contour (+) wound operation closed by 3. IAH grade 2 (ICD 10 CM S.13)
gauze
- Auscultation: Bowel sound (-)
- Palpation: Muscular rigidity (-)
- Percussion: Liver dullness (+)

August 25 On BP : - Post laparotomy + repair defect Patient passed away


2018 sedation HR: no beat hernia
RR: - COD : Severe sepsis
Pupil : (5 mm/5mm, light reflex (-/-) 1. Total mechanical bowel
ICU D obstruction due to incarserted
POD 2 S/L ar Abdomen of the left lateral inguinal
- Inspection : Distention (+), darm hernia (ICD 10 CM K59.69)
14.25 contour (+) wound operation closed by 2. Septic shock (ICD 10 CM N.10)
FM gauze 3. IAH grade 2 (ICD 10 CM S.13)
- Auscultation: Bowel sound (-)
- Palpation: Muscular rigidity (-)
- Percussion: Liver dullness (+)
Patient identity
• Name : Teuku noval
• Age : 14 Years old
• Sex : Boy
• Address : Ds. Bentara, Kab Bireun
• CM : 1 18 24 93
• Admission time : 18.30 Wib
• Drive license : (-)
Time response

Date/Time Examinat Laboratory Radiology Time Date/Tim DPJP


patient ion hour Examination Examination of e patient
came to ER Diagn out from
Send Result Send Result ostics ER

August 23th 18.30 18.45 19.30 20.15 20.45 21.00 August DR. dr.
2018 23th Imam
WIB WIB WIB Wib Wib Wib Hidayat,
18.30 23.00 Sp.B (K)
WIB
WIB
Chief complain
• Decrease of consciousness

Presenting history
• Patient was referred from Bireuen district
hospital to Zainoel Abidin emergency room
with chief complaint decrease of consciousness
for 12 hours ago.
• Initially the patient was riding a motorcycle
without helmet and suddenly he fell down to
the ditch beside the road.
• There was no history of lucid interval
• There was no history of seizure
• There were history of nausea and vomiting
• Eyes open to verbal, motoric purposeful
movement to painful stimulus, and verbal
confused conversation, but able to answer
questions.
Physical examination :
Primary survey
• A : Clear, C-Spine control
• B : Spontaneous, RR = 24 breaths/minute
Right hemithorax Left hemithorax
Inspection Symetrical, trachea in midline, JVP in normal limit

Palpation Crepitation (-) Crepitation (-)


Stem fremitus normal Stem fremitus normal
Percussion Sonor Sonor
Auscultation Ves (+), rh (+), wh (-) Ves (+), rh (-), wh(-)

• C : BP : 110/70 mmHG, Pulse : 98 beats/minute


• D: GCS = E3 M5 V4 = 12, Isochoric Pupil (unable to be
examined/3mm), Light Reflex (+/+)
E:

L/S At right temporal region


Look : Hematome (+), excoriated wound (+)
Feel : Step off (+)
L/S At The Upper Face
Look : Swelling (+), Lacerated wound (+) was
sutured at the right frontal size 4 x 1 cm.
Feel : Step off (+)
L/S At The Middle Face
Look : Asymmetrically, lacerated wound (+) was
sutured side 2 x 1 cm, hematoma right
orbita.
Feel : Step off (+)

L/S At The Lower Face


Look : Exoriated wound (+). side size 1 x 0,5 cm at
the labia oris inferior.
Feel : Step off (-)
L/S Intra Oral
• Maloclussion (-)
• Dental Loss (-)
• Step Off Deformity (-)
• Cross Bite (-)
• Open Bite (-)

Visus & Eye Movement :

• Right eye was Unable to be examined


• 6/6 left eye
Secondary survey
Head and Neck 
L/S At right temporal region
Look : Hematome (+), excoriated wound (+)
Feel : Step off (+)
L/S At The Upper Face
Look : Swelling (+), Lacerated wound (+) was
sutured at the right frontal size 4 x 1 cm.
Feel : Step off (+)

L/S At The Middle Face


Look : Asymmetrically, lacerated wound (+) was
sutured side 2 x 1 cm, hematoma right orbita.
Feel : Step off (-)
L/S At The Lower Face
Look : Exoriated wound (+). side size 1 x 0,5 cm at the labia
oris inferior.
Feel : Step off (-)

L/S Intra Oral


• Maloclussion (-)
• Dental Loss (-)
• Step Off Deformity (-)
• Cross Bite (-)
• Open Bite (-)

Visus & Eye Movement :


• Unable to be examined right eye
• 6/6 left eye
Thorax  in normal limit
Abdomen  in normal limit
Upper extremity  in normal limit
Lower extremity  in normal limit
• Vas : 8
Assessment :
1. Moderate head injury
2. Suspect open depressed fracture of the right
frontal region
3. Suspect fracture of the right maxilla
Management
• Stop oral intake
• Head Up 300
• O2 8 L/ minute via face mask
• IVFD NaCl 0.9% 20 drips/minute
• Ceftriaxone inj. 2 gr
• Tramadol inj. 100 mg
• Tetagam inj 250 iu
• Laboratory examination
• Radiology examination
Laboratory result
• Hb : 10,8 gr/dL
• White blood count : 12.500/uL
• Platelet : 285.000 /uL
• Ht : 27 %
• CT : 2”
• BT : 7”
Radiology result
Head CT-Scan
• There was SCALP hematoma at the right fronto temporal
• There were hyperdense appearance at the right fronto temporol region
 ICH
• There were hyerdense biconvex at fronto-temporal region  EDH
• Sulcus and gyrus were narrow
• Cysterna and System Ventricle were normal limit
• There was no midline shift

Head CT Scan 3D
• There was discontinuity of bone at the right maxillofacial bone
• There was discontinuity of bone at the right frontal
• There was discontinuity of bone at the right rima orbita inferior
Cervical lat
• Loss of lordotic

Thorax Ap
• Lung contusion
Diagnose :
1. Moderate head injury
2. EDH at the right frontal
3. ICH at the right fronto-temporal
4. Open depressed fracture of the right frontal region
5. Fracture of the right inferior orbital rim
6. Fracture of the right maxilla
7. Fracture of the right frontozygoma
8. Lung contusion at the right hemi thorax
Consult to neurosurgery division :
• Craniectomy evacuation ICH emergency

Consult to plastic surgery division :


• ORIF Elective

Consult to TCV division


• Conservative therapy
• Nebule ventoline 1 respule / 8 hours
• Inj. Methylprednisolone 125 mg / 12 hours
Operative report
• Performed question mark incision at the right
temporoparietal
• Performed 5 burrholes
• Bone was pull out  duramater was tense and
found EDH evacuation EDH
• Performed dura hit stiches
• Duramater was opened sharply-- > found ICH, 20 cc
 evacuation ICH
• Performed durafacial graft
• Bone was kept at subgaleal
• Inserted one tube drain
Post Operative Diagnose

Post craniecotomy evacuation EDH + ICH


1. Moderate head injury (ICD 10 CM S.09)
2. EDH at the right frontal region (ICD 10 CM S.06)
3. ICH at the right fronto-temporal (ICD 10 CM I.61.9)
4. Open depressed fracture of the right frontal region
(ICD 10 CM S.12)
5. Fracture of the right inferior orbital rim (ICD 10
S.02.32.XA)
6. Fracture of the right maxilla (ICD 10 CM S.02.401.A)
7. Fracture of the right fronto zygoma (ICD 10 CM
S.08.0)
8. Lung contusion at the right hemi thorax (ICD 10 CM
S.27.329.A)
Follow up
Date S O A P

August 27th Pain General condition : Post craniecotomy evacuation • Head Up 30ᵒ
2018 decreased Good EDH + ICH • IVFD Nacl 20
1. Moderate head injury
BP : 110 / 80 mmHg drips/minutes
(ICD 10 CM S.09)
POD Pulse : 80x/minute 2. EDH at the right frontal • Inj. Ceftriaxone 1 gr/12
4 RR : 20x/minute region (ICD 10 CM S.06) hours
T : 37 OC 3. ICH at the right fronto- • Inj. Ketorolac 30 mg
GCS : 15 (E4M6V5) temporal (ICD 10 CM • Nebule ventoline 1
HCU pupil isochoric I.61.9) resepule / 8 hours
4. Open depressed fracture
Surgical (3mm/3mm), Light Reflex (+/+) • Inj. Metylprednisolone
of the right frontal
region (ICD 10 CM S.12) 125 mg / 12 hours
Right Left L/S at the right frontol region 5. Fracture of the right
hemithorax hemithorax
Look : Wound (-), hematoma inferior orbital rim (ICD Planing
(+), swelling (+) 10 S.02.32.XA) • Observation vital sign
Inspecti Symetrical, trachea in midline, Feel : Pain (+) 6. Fracture of the right • ORIF Elective
on JVP in normal limit maxilla (ICD 10 CM
S.02.401.A)
L/S At The Middle Face 7. Fracture of the right
Palpati Crepitation (-) Crepitation (- Look : Asymmetrically,
on Stem fremitus ) fronto zygoma (ICD 10
normal Stem lacerated wound (+) was CM S.08.0)
fremitus 8. Lung contusion at the
normal
sutured side 2 x 1 cm,
hematoma right right hemi thorax (ICD
Percuss Sonor Sonor 10 CM S.27.329.A)
ion
orbita.
Feel : Step off (-)
Auscult Ves (+), rh (-), Ves (+),rh (-),
ation wh (-) wh(-)
Patient identity
• Name : Muhammad Asyraf
• Age : 5 Years Old
• Sex : Boy
• Address : Tanjung Ulim. Kab. Pidie Jaya
• CM : 1 18 24 95
• Admission time : 17.15 Wib
• Body weight : 25 Kg
Time response
Date/Time Examina Laboratory Radiology Time Date/Tim DPJP
patient tion Examination Examination of e patient
came to ER hour Diag out from
Send Result Send Result
nosti ER
cs
August 17.15 17.40 19.15 - - 17.30 20.30 DR. dr.
23th 2018 Wib Wib WIb Wib Wib Safrizal
Rahman,
17.15 Sp.OT
Wib
Chief Complain

• Pain and difficult to move the right leg

History Of Present Illness

• The patient was referred from Aceh Pidie district hospital to


Zainoel Abidin emergency room with chief complain pain and
difficult to move the right leg since 8 hours ago.

• The patient was riding a bicycle then suddenly hit by a


motorcycle from beside of him then fell off.
• There was no history of unconsciousness
• There was no history of nausea and vomiting.
• Eyes open spontaneously, motoric obey to
command and verbal with good oriented to
person, time and place
Physical examination :
Primary survey
• A : Clear
• B : Spontaneous, RR = 18 breaths/minute
Right hemithorax Left hemithorax
Inspection Symetrical, trachea in midline, JVP in normal limit
Palpation Crepitation (-) Crepitation (-)
Stem fremitus normal Stem fremitus normal
Percussion Sonor Sonor
Auscultation Ves (+), rh (-), wh (-) Ves (+), rh (-), wh(-)

• C : Pulse : 87 beats/minute, Blood pressure : 110/90 mmHg


• D : GCS = E4 M6 V5 = 15, Isochoric Pupil (3mm/3mm), Light
Reflex (+/+)
• L/S at the right lower leg

Look : Swelling (+), deformity (+), lacerated wound


size ± 1 cm X 0,5 cm, irreguler, based of wound
was bone (+)
Feel : Pain (-), NVD (-)
Move : ROM Limited
Secondary survey
• Head and neck  In normal limit
• Thorax  In normal limit
• Abdomen  In normal limit
• Upper Extremity  In normal limit
• Lower Extremity 
• L/S at the right lower leg
• Look : Swelling (+), deformity (+), lacerated
wound size ± 1 cm X 0,5 cm, irreguler,
based of wound was bone (+)
• Feel : Pain (-), NVD (-)
• Move : ROM Limited
VAS : 6

Mild 1-3 Moderate 4-6 Severe 7-10


Non opioid + Opioid + nonopioid Opioid + nonopioid
adjuvant + adjuvant + adjuvant
- COX-2 - Codein - Oxycodone
- Ibuprofen - Propoxyphene - Morphine
- Aspirin - Hydrocodone - Hydromorphone
- Acetaminophen - Tramadol - Fentanyl
Assessment :
Open fracture of the right leg
Laboratory result
• Hb : 12.6 gr/dL
• White blood count : 10.500/uL
• Platelet : 174.000 /uL
• Ht : 32 %
• PT : 9.5”
• APTT : 32.9”
Right cruris AP/Lat :
•There were discontinuity of bone at the
middle third of the right tibia and fibula
Diagnose :
Open fracture of the middle third of the right tibia
and fibula grade 1 (ICD 10 CM S08.38)

Consult to orthopedic division :


• Debridement + ORIF Emergency
Operative Report :

• Performed debridement with normal saline +


peroxide + povidone iodine until clean
• Incision at the later tibial crest of the right leg
• Identification fracture site at the middle third of the
tibia
• Performed reposition and fixation tibial bone with
narrow plate 7 holes 7 screws
Post Operative Diagnose :
Post debridement + ORIF
Open fracture of the middle third of the right tibia
and fibula grade 1(ICD 10 CM S08.38)
Follow Up
Date S O A P
August Vital sign: Post debridement + IVFD RL 1600 Cc/24
27th Pain • HR : 94 beats/minute ORIF Hours
2018 • RR : 22 Inj. Cefazoline 250 Mg
breaths/minute
• Open fracture of Inj. Metamizole sodium
Rauda • Temp : 36.90 c
the middle third of 500 Mg
2
the right tibia and
POD 4 L/S at the lower right left
fibula grade
high Planning:
1(ICD 10 CM
S08.38) • Mobilisation
L : Wound dry (+)
F : Pain (+), NVD (-)
M : ROM limited